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PROOF OF INSURANCE (2018 - 2019) CLOSED AC' R0 CERTIFICATE OF LIABILITY INS SU DATEIMMIDDIYYYY) NCE 5/7/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, It the certificate holder is an ADDITIONAL INSURED, the Policy(les) must be endorsed. II SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this cortificate does not confer rights to the certificate holder In lieu of such endolrsement(s'). PRODUCER ... .. ..... �%li�Julle gong .. .. 1.plANk,.RN�I, IQ Risk (949)679-3701 (949)679-3700 7tek'co ,.-.____ ...m..._..... r 9- 0 0 ance m 38 8xocutiverPsrk,$Suitee320LLC jm�or( .�m.................w..3.... ....,.. .. Irvine, CA 92614 INSURER(sIAFFQ,RDINQ, _,....... , COVERAGE MNatiass5EasITmmGaarwaraca,ata _.. 38910 ._ . INSUREDI y 4 ReI�I�_Falls Lake Fine and Cad�ualt 1588 , CC LAYNE A SONS INC. INSURERc .,., ..... 216 Standard Street !NSUW : ., .............�.w.._w..,wwww-._...,...... . ..................................,.....wwww..,.....,..................,...............................,. .,.., E1 Segundo, CA 90245 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER:CL182103315 REVISION'NUMBER- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LI D BELOW HAVE BEENISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 0 I Y REQUIREMENT, TERMCONDITION F ANY CONTRACTO OTHER DOCUMENTET TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS D CONDITIONS OF SUCH POLICIES.LIMITS Y HAVE BEEN REDUCED BY PAID iPOU-0,00 PAICLAIMS. YY). gK§W .LS(a(' POU .EYPoLlVEip LTR INSURANCE ' NUMBER Y �i COMMERCIALLIMITS LITY EACH GENERAL el �6 ; 1,000,000 OCCUR , 100,000 A C S ( ... X Y 010061552-0 7/1/7018 2/1/2019 MED EXP( ) axClndald PERSONAL A AM IWURY i 1,000, S,,FN L AGw','v RC(G.A"I";LIMIT APPLIES PER GENERAL AGGREGATE ..S 2,000,000 x Pof'1(^y C I L .S 2 0 000 PRD- JI�CT PRO TS- MPTP . 00, OTHER AUTDMOWLELIABILITY .. .. I, MtII'JV('MV7'kil'+(Cmk, �ldda(p1. . Bwlora.lNc�d(IAIIa.. _ .. ... ANY ADDILY INJURY(P ) 9 - ALL OVMED SCHEDULED LED AUT Ain BODILY I j, „, ....,..,.., _--- .......: L HIRED AUT AUTOSED (p9rAp" uRMn.................................. 1 LIAR tl PuCXU p A EXCESS CLAMS-M AREGNTs A000wY00q DD RETENrIPN$ 0100061562-0 2/1/2018 2/1/2019 1 yy PEk 0101, .I�. .,... ............................ 13 IMandam(oryInNH, AP"aall,Ixl. Mrr'Ihl J 1 oo8293-00 2/1/201 2/1/2019 L ¢rlaR: a! I'AEkuR I)bL,al„s 1.000.000 M L L CAG 1 ACC6DC y� ELDISEASE-POLICY... pgn v ( I ., Lw 1C, / u IT I6 1.000,000 ,1b(^�1+(":RIK�1 Y4)F�I("7F C7F'FI�NA"i'V(7hd',�N'�*p¢'NM DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLE-(ICORD 101,Addldonal Remarks Schedule,may be attached N mora apace to required) *10;Days Notice of Cancellation for Non-Payment of Premium. The, City of 81 Segundo is named as Additional Insured per General Liability. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of 81 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 350 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. 81 Segundo, CA 90245 AUTHORIZED REPRESENTATIVE Julie Wong/JULIE ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION Attached To and FormingPart o Poli E ective Date o Endorsement 7Nomed insure f ry � fd ' 0100061552-0 02/01/201812:01AM at the Named Insured yne&Sons Inc address shown on the Declarations Additional Premium., Return Premium: $0 $0 This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE _ Name of Additional Insured_Person(s)or Organization(s): Location(s)of Covered Operations Blanket,as required by written contract. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section 11—Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s) or additional insureds,the following additional exclusions organizatlon(s) shown In the Schedule, but only with apply: respect to liability for "bodily Injury", "property This insurance does not apply to "bodily Injury" or damage or personal and advertising Injurycaused, "property damage"occurring after: in whole or in part,by: 1. All work, including materials, parts or equipment 1. Your acts or omissions;or furnished in connection with such work, on the 2. The acts or omissions of those acting on your project (other than service, maintenance or behalf; repairs) to be performed by or on behalf of the in the performance of your ongoing operations for the additional Insured(s) at the location of the covered additional Insured(s) at the location(s) designated operations has been completed;or above. 2. That portion of"your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 2010 07 04 0 ISO Properties,Inc.,2004 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS Attached To and FormingPort o Poli Effective Date o Endorsement f Policy ff f Nomed Insured 0100061552-0 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc address shown on the Declarations $ Additional Premium: Return Premium: This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s) Location and Description of Completed Operations Blanket,as required by written contract. EXCLUDES ALL NEW RESIDENTIAL CONSTRUCTION "Your work"does not include"new residential construction",which means any building or structure not previously occupied,and designed or intended for occupancy in whole or in part as a residence by any person or persons."New residential construction"does not include apartments or apartment buildings or assisted living facilities. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. Section II—Who Is An Insured is amended to include as an additional insured the person(s) or organizations) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location desig- nated and described in the schedule of this endorse- ment performed for that additional insured and in- cluded In the"products-completed operations hazard". ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 20 37 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY,PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT Attached Ta and forming Part of PolicyEffective Date of Endorsement Named Insured 0100061552-0 02/01/201812:01AM at the Named Insured C C Layne&Sons Inc address shown on the Declaratlons Additional Premlum Return Premium: $0 $0 _..__.�. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE PRODUCTS POLLUTION LIABILITY COVERAGE The insurance provided to Additional Insureds shall be excess with respect to any other valid and collectible insurance available to the Additional Insured unless the written contract specifically requires that this insurance apply on a primary and non-contributory basis,in which case this insurance shall be primary and non-contributory. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS5003 0717 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US-BLANKET �W,_chQT6_a_nd—Forming Port of Policy Effective Date 11 of Endorsement r I I--1—--.__.'7Name.d insured.... nsu.r,ed 0100061552-0 02/01/2018 12:01AM at the Named Insured C C Layne&Sons Inc address shown on the Declarations .................................... m.,,., ....w_....w_ ,,, .__............._.._............". ... ..... 1"Additional Premium: Return Premium: 1 so 0 This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE SECTION IV—CONDITIONS,8.Transfer of Rights of Recovery against Others to Us is amended by the addition of the following: We waive any right of recovery we may have against persons or organizations because of payments we make for injury or damage arising out of"your work"done under a written contract with that person or organization wherein you have agreed to provide this waiver. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS4002 0110 Page 1 of 1 AC CERTIFICATE T F LIABILITY ........_. ... 05/21/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFO TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT, If the corti'ticate holder Is anADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSUREDprovisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this corti'flcato does not confer'right's to the certificate holder In Itou of such endorsement(*). a�aPRODUCER COMA0 Tom BPundid a License 0479988 F71oNE .Ymm......Ole Hernandez r Is AX . 10-322.0831 "•MA,AIL P�„l'tcranx�agNamttk°alrroduago vont.,,,, t ,'.1 w 214 Standard St. Ste 8 �PNIN"hll ER AFFORDING EI Segundo CA 90245 P State IF-arrRri Mutual Automobile sur Company 61L s ................ Isu111111 A: Insurance t'atlra>an 2517& INSURED INSLIRER a: C C LAYNE&SONS INC eN c: ......................®r.....,....... 216 STANDARD ST i INSURER RISUREA E: EL SEGUNDO CA 90245 INSURM., F COVERAGES CERTIFICATE NUMBER: REVISION i NUMBER: THIS IS TO Cl R'rPFY' T'HA'I I'IjF PO ICtP S OF WSpYfdC4N t: 9 NSIED BELOW HAVE BEEN iSSL)'l:D TO E INSURED NAMED ABOVE FOR THE POLICY rrElr�laJt� INDICATED. N.OTWI'lllSTANLANG,ANY AEOUIRCMENt I'I:RM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 8l. I a;tAD 11r1 MAY PERTAIN. 1HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS CONDITIONS uAaiurr SUCH POLICIES,LIMITS SHOWN MAY HAVE BEENP IC REDUCED'BY PAIDCLAIMS.EACH 4'11 Ctjf?R d+s�w I1i uofYCk' rr wYw TYVErJr IINSURANCEY "Pjy� ICd, I 1M10'TS C11 OMMERaaA GENERA 1 ,�M k�CI t"I9 Iii b4 tl 4 l CLAIMS-MADE OCCUR ..ED EXP INri ¢e� �rarlw�mlq �� ..N'LGGREGA❑TE.....C..... fur R�O AL I—ADV INJURY S LIMIT APPLIES PER ... .. ICY PERQ LOC ,..41a,E rpf,I�dY,A.rnr�"y�kkl"�,�,n k: 1 r"6a910!1!S•COMPIOP AGG 1 . ......_..._..4;11'ddk'i,,..._.. ............... . . auTOMOBM LIABILITY ANYAuro Y Y 499 1656-C26-75C � INr �r"dk°d4MI� s 1,000.040 03/26/2018 09128!2018 w mm _ BODILY INJURY(Per pwsw) $ QUAUTOSED BODILY INJURY.(P...... "..' .. A OS ONLY Per ep:ruNuddm^+I,P S PROP HIRED NON-OWNED LY ,,,,,„,,,,,,��.,,,,,,,,,,..�....._m wl”4vdt'4efftllP'111MINJu:d@,,,,. — UMBRELLA LIAR OCCUR Y ., S AUTOS ONLY A II EXCESS LIAe..,,,, ;7LMIY.T* ECHLC.�4TIM"dd6..P�r,..L Ndd.bl ryry ---» - "rIF1;I9�d_I.PN u_I�I�kI r'p&��Ca d�I�1'IN81.DMbI, LLABUW ANYCrwk F. IpPdYERt N$AN N�CN) I{P4d' Y 1YaR11E COMPENSATION IN ® El El 1�,4 ha Af:rl 117k•Mdl,,, f. I drd si d,,Nrk VN: NIA VtJIMNFMAIb�kd C�^L Msarozlelcory In NRI MA �r�d Mdil:'�d:artl^wb wuY�Iear 4'I d'SIJEA.iL EAf dr&d-k.,47 M"IWA S I, I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,AdMOW Remarks ectodule,any be dWchad N mom apace is ) 2006 FORD F350 SO CREW CAB VIN 1FTWW31P46EA08216 Job site:Vista Park ........... �..............................._W. � W_ CERTIFICATE HOLDER !CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of EI Segundo ACCORDANCE WITH THE POLICY PROVISIONS. 350 Main St AUTHORMED REPRESENTATIVE ElSegund CA 90245 ®1988'» 0'tlCORD "PORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD 1001483 132810.12 03-16-2016 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 225% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective:05/22/2018 Policy No.FLA008293-00 Endorsement No. Insurance Company: Falls Lake Fire&Casualty Company Insured:CC LAYNE&SONS INC.(A Corp) Countersigned By ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved.